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Adverse Events In Minnesota Hospitals And Surgical Centers

Armen Hareyan's picture

New consumer guide and interactive Web site complement this year's report

The Minnesota Department of Health (MDH) today released the third annual report on preventable adverse events in Minnesota hospitals, ambulatory surgical centers and regional treatment centers. Preventable adverse events include such things as wrong-site surgeries, pressure ulcers, retained objects after surgery, death or serious disability from a medication error, and death from a fall.

The report summarizes the number and types of events that occurred between October 7, 2005, and October 6, 2006, in facilities that are required to report. According to the report, during that period, 154 adverse events were reported by 49 facilities, and 24 deaths and 7 serious disabilities resulted from the events.

This year's report highlights steps being taken by facilities to prevent adverse health events, and is accompanied by a new consumer guide and interactive Web site. The consumer guide provides easy-to-understand information about the adverse events reporting system and practical tips for working with health care providers to ensure safe care. The interactive Web site allows consumers to select specific hospitals and surgical centers to see what, if any, adverse events have been reported by that facility, and also links consumers to broader sources of quality and safety information.

"Our adverse health events reporting system is providing the type of information that is helping us improve the quality and safety of care in Minnesota," said Minnesota Commissioner of Health Dianne Mandernach. "Since the reporting system began three years ago, hospitals and surgical centers have stepped up their efforts to find, report and fix medical errors, and those efforts are beginning to pay off."

Mandernach said that an increase in the number of adverse events should be viewed as a sign that the system is working. "Minnesota's facilities are looking harder for reportable events, and that's a positive step," Mandernach said. "Developing better strategies to prevent adverse events depends on obtaining more and better information."

The report notes that the most frequently reported event was a stage three or four pressure ulcer (serious bed sores) (48); the next most frequently reported event was a foreign object left in a patient after surgery (42).

In addition to reporting individual events, facilities are required to report on the underlying causes of each event and the corrective actions being taken to prevent similar events from happening in the future. This reporting system provides a forum for sharing key findings with hospitals and surgical centers across the state so they can learn from one another. Generalized information from the adverse health events reporting system is also shared with facilities through newsletters highlighting best practices, safety alerts and presentations throughout the year.

With collaborative leadership from MDH and the Minnesota Hospital Association, Minnesota's hospitals are implementing a variety of strategies for preventing many types of errors. Such strategies include establishing multidisciplinary skin care teams to identify and prevent pressure ulcers before they become serious, developing new ways to track sponges and other objects used in surgical procedures, ensuring that procedures for counting those objects are thorough and consistent throughout a facility, clarifying policies both inside and outside the operating room to ensure correct site surgery, and improving how patients are assessed for the risk of falling or developing a serious pressure ulcer.

The legislation creating the adverse health event reporting system was championed by Minnesota hospitals and was signed into law by Gov. Pawlenty in 2003.

The law requires all Minnesota hospitals, ambulatory surgical centers and regional treatment centers to report to MDH whenever any of 27 events occur. The National Quality Forum, a Washington, D.C.-based health care standards-setting organization, created this list of adverse events in 2002 at the request of the federal government. This followed an Institute of Medicine report estimating that medical errors in hospitals cause 44,000 to 98,000 deaths every year in the United States.

Mandernach said that consumers should use information in the report and the new consumer guide to become more involved in their health care.